As seen in Psychology Today.
This is an ongoing series that offers guidance to friends and family who are worried that someone they know and love may harm themselves or others. These posts are being published throughout May to honor Mental Health Awareness Month.
The first part of the series, which was posted on May 7, provided information about how widespread the mental health crisis in the United States is, noted the differences between mentally unhealthy individuals and individuals with mental illnesses, and described a few methods as to how one can take the initiative when confronting someone who you feel may be a danger to themselves. In the second part, which was posted on May 14, I focused on the importance of persistent treatment for individuals with severe mental illnesses, noted that patients with severe mental illnesses are not more inclined to violence than the general population, and offered some guidance for those whose loved one have indicated they may be a danger to themselves or others.
This post will provide a walkthrough of what happens should a person who may be a danger to themselves or others be brought to the hospital. It should be noted that the following applies to New York State, and that the statutes and regulations governing mental health laws vary from state to state. This applies to the length of time an individual may be involuntarily hospitalized and the degree of danger they present to themselves or others.
The final part in the series, to be posted May 30, will examine some of the laws that were implemented to protect those with mental illnesses and how some of these laws, as well-meaning as they may be, can oftentimes make it more difficult to provide effective treatment to those with severe mental illnesses.
The Decision to Hospitalize
The decision to hospitalize someone for fear that they may be a danger to themselves or others should not be made at the first signs of psychosis, mania, or depression. It should be considered when you fear that they are in imminent danger of harming themselves or others.
To clarify, an individual may be considered a threat to others if they are openly making threats, stockpiling or have access to weapons, or indicating that delusions or hallucinations are compelling them to commit violent acts. If an individual indicates that they may inflict harm upon themselves or commit suicide, then the same might be true because they pose a potential threat to themselves. Additionally, those who cannot care for themselves or who are neglecting their own basic needs due to mental illness can also be hospitalized involuntarily if their condition is severe enough. Examples include living in abject squalor, or inability to tend to basic needs due to depression, mania, or psychosis. Whether the cause is due to depression, bipolar disorder, schizophrenia, or drug-induced psychosis, a person who presents an imminent or potential threat to themselves or others as described above may be involuntarily hospitalized based on the evaluation by the psychiatrist.
While it is better to accompany your loved one to the hospital for treatment, this may not be an option. If you feel as though they may become more of a threat to themselves or others at the suggestion of hospitalization, you should call 911. However, keep in mind that the situation may escalate if the police become involved and calling 911 should be done if you believe they are not well enough to be voluntarily taken to the hospital. Furthermore, as mentioned in a previous post, should you decide to call 911, it is imperative that you inform the operator that your loved one has a mental illness and request a mobile crisis team.
Arriving at the Hospital
Ideally, you should take your loved one to a hospital with a dedicated psychiatric emergency room (also known as a Comprehensive Psychiatric Emergency Program or CPEP). Unfortunately, this is not always an option. Because there have been significant cuts to psychiatric services across the nation and the number of psychiatric beds has been in steady decline for decades, access to a psychiatric emergency room is not available in some parts of the country. Consequently, patients in these regions will be required to wait in medical emergency rooms to receive an evaluation. This is a symptom of a larger problem with the nation’s health care system, but, at present, beyond the scope of this post.
Once present at the hospital, your loved one may have to wait to be evaluated by a medical professional. If it is a hospital without a CPEP, they will be monitored by hospital staff. Eventually, they will be assessed by a psychiatrist who will determine if they are someone who poses a threat in any of the ways indicated above. The psychiatrist may determine that they do not need to be admitted, and that outpatient care is the best course of action. Conversely, the psychiatrist may feel that it is necessary to admit your loved one.
The procedure is slightly different in a hospital with a CPEP. The first thing that you will notice is that CPEPs are secure spaces. There are locked doors, metal detectors, and it is monitored by hospital police. When you enter a CPEP, it will feel similar to going through security at the airport. You will then enter the waiting area, which is also known as the non-detainable area. You will be briefly evaluated by a member of the psychiatric team to determine whether the person should be immediately detained or if they are well enough to stay in the non-detainable area, which would permit you to leave the CPEP if you chose to do so.
A medical professional will then approach you and your loved one and request some information. Following the consultation, they will then escort your loved one to an area for evaluation. This area is a detainable area—they will not be allowed to leave until they have been assessed by a psychiatrist even if they entered the CPEP of their own volition. It is now the choice of the team at the hospital to determine if it is safe for them to leave, and they will consider the patient’s history, what family members say, and their current mental state to come to that determination.
In New York State, if the team determines that the patient is a danger to themselves or others, they may be admitted to the hospital or they may be placed into the extended observation unit for 48 hours. The latter is utilized when a patient’s psychosis is drug-related and likely to wear off once the drugs have been metabolized, for diagnostic clarification, or for collateral information. If, following the 48 hours, they are deemed to no longer be a threat to themselves or others, they will be released. If not, they will be admitted to the hospital.
Once admitted, patients are granted additional rights by New York State law. For example, during the evaluation, the psychiatric team can speak with family members to obtain a history of the patient’s behavior with or without the patient’s consent. If the patient is admitted, they have the right to forbid the psychiatric team from speaking with family members. They also have the right to deny the psychiatric team the ability to examine their records from other hospitals. However, if the patient explicitly makes threats to an individual or group of individuals, the hospital has a duty to inform them of the threat—this is known as the “Tarasoff” rule, which is in reference to the court case Tarasoff v. Regents of the University of California. While most states, including New York (see Section 9.46 of New York State Mental Hygiene Law), have adopted this rule or a variation of it, there are some states where psychiatrists do not have such a duty.
Voluntary Admission (Mental Hygiene Law Section 9.13)
Hospitals may admit patients who voluntarily request to be admitted under Section 9.13 of New York State Mental Hygiene Law. They may remain in the hospital for a maximum period of six months. If at any point during this time they decide they would like to leave, they must put the request in writing and submit it to the hospital. Once the document has been submitted, the hospital has a 72-hour period to decide if the patient should be discharged or not. If the hospital determines that they should remain, then their status changes and they are converted to an involuntary status under Section 9.27 of the Mental Hygiene Law (see below).
This change of status permits the hospital to hold the patient for a maximum of 60 days and upon expiration may require a court order for further hospitalization. If at any point during the hospitalization the patient disagrees with the hospital, they can take the matter to Mental Hygiene Court, as all patients have a right to a hearing under Section 9.31 of the state’s Mental Hygiene Law.
Involuntary Admissions (Mental Hygiene Laws Sections 9.27 and 9.39)
Hospitals may admit patients involuntarily, provided they present a danger to themselves or others. These are known as emergency admissions and they are governed by Section 9.39 of New York State Mental Hygiene Law. Section 9.39 stipulates that patients may only remain in the hospital for a maximum of 14 days, and that this 14-day period begins once they are admitted. As mentioned above, if the patient believes that they should not be held against their will, they can take the matter to Mental Hygiene Court.
If the patient continues to show signs and symptoms of psychiatric illness or potential danger to self or others at the end or close to the end of the 14-day period, Section 9.27 of the state’s Mental Hygiene Law allows the psychiatric team to hold the patient for a maximum of 60 days. Alternatively, the team may ask the patient to switch to a voluntary status (Section 9.13), thereby allowing them to remain in the hospital up to six months. If they refuse, the hospital can petition the Mental Hygiene Court for permission to keep the patient another 60 days. The patient has the right to challenge this decision.
Mental Hygiene Court
In many instances, there may be a court within the hospital, particularly if the hospital is home to a CPEP. Known as Mental Hygiene Court in New York, it operates in a manner akin to civil or criminal courts. It is presided over by a judge, the hospital and doctors have an attorney, and the patient has an attorney.
During the court proceeding, a judge will assess the evidence in favor of and against continuing to hold the patient. Some pieces of evidence, however, may not be admissible in the court. If you spoke to the psychiatric team before your loved one was admitted, and you provided information that they later deny and say cannot be used in court, then the judge may rule that it cannot be used as evidence.
Following testimony from doctors and the patient, as well as a close examination of the evidence, the judge will determine whether the patient is a threat to themselves or others. If it is decided that the patient is still a threat, then New York state law allows the judge to order the continuation of the involuntary hospitalization. If the judge rules that the patient no longer poses a threat to themselves or others, then they will be discharged.
Apart from the court proceedings for involuntary hospitalization, the court also hears cases concerning treatment. While patients have the right to refuse treatment under New York State Mental Hygiene Law, the hospital may seek a hearing for treatment over their objection if the treating psychiatrist deems it necessary to medicate. During these hearings, all parties testify and provide evidence for the judge to decide if the treatment over objection is necessary or not. Depending on the outcome of the hearing, the treatment may be initiated or the patient may be released.
It should be stressed that this is a complicated matter and oftentimes confusing to both patients and their friends or families, in part because psychiatric care is governed by New York State Mental Hygiene Law and not civilian law. NYS Mental Hygiene laws afford patients numerous rights to maintain their liberty and ability to determine their own lot in life, but also recognize that severe mental illnesses can severely impair a patient’s judgment, and that, if left untreated, their illness may cause them to harm themselves or members of the community.
In the final part of this series, we’ll look at some of the laws and court precedents in New York that exist to regulate this process.